44 VALLEY ST - BUILDING INSPECTION zq; zz5°�
The Commonwealth of Massachusetts
�• Board of Building Regulations and Standards CITY OF
RECEIVED sALEM
Massachusetts State Building Code, 780 CM%SPECTIONAL ;FR2v A E&%,2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling 10! 1
This Section For Official Use Only
Building Permit Number Date A lied:" -
Nt\
Building Official(Print Name) Signature ; Date
^" .SECTION I:SITE INFORMATION
_ 1.1 P�perty Alldr s: S-f
L la Is 1.2 Assessors Map& Parcel Numbers
�) this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq do Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY,OWNERSHIP' s.
2.1 Owner' d ofRe : _
/ Iaz
Name(Print( n)Z City,State,ZIP
q !fu Iley S ..
No.and Street Telephone Email Address
-SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other In Specify: /I7 . .,-, se
Brief De cription of Propose�d W rk2: -- fe f 4. 3 �/ n"
%en rmm 7P% ovecP � .�ry /J-
'SECTION 4: ESTIMATED CONSTRUCTION COSTS '
Estimated Costs:
Item Official Use Only.
(Labor and Materials)
I. Building $ L Building Permit Fee: $ Indicate how fee is determined:'
❑Standard City/Town Application Fee.` it
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier . x `-
3. Plumbing $ 2. Other Fees: $ - :" •�
4. Mechanical (HVAC) $ List i
5. Mechanical (Fire '
Suppression) $ _Total All Fees:$
Check No. Check Amount 'Cash Amount
6. Total Project Cost: $ � ❑ Paid in Full 13 Outstanding Balance Due: ' 14
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SECTION 5: CONSTRUCTION SERVICES '
5.1 Co struction Supervisor License(CSL) 660 a d
aak/
T,Q(+,�h g, License Number Er nation Dale
Name of CSL Hol er i
Lis[CSL Type(see below) L/
?3 aN-&ef xet
No.and treet Type _ L Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
S 1�1IPA G /l�), Im R Restricted 1&2 Family Dwelling
City/town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
78� 7a9-��vo I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Ail/c /;W//7, - HIC Registration Number .pira on Dale
HIC C7ompa� lane HIC l2egistr�J'I Name
-� ke Z�' L� I��T
Noir�.aa d Site Email address
J"JM3a:n. (/YI/`t 7�i� 7.t4- VUa'a
City/Town, State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
..:SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize f2S/✓1 P ti 7( ll At
to act on my behalf,
,iin all matters relative to work authorized by this building permit application. /
NA
Print Ownerj Name(Ele Ironic Signature) Date
SECTION 7b: OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
containedd in this applicationis true and accurate to the best of my knowledge and understanding.
i�%�VIZz.'a rl
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Print Owners or Authorized Agent`s Name(Electronic Signature) ate
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dus
2. When substantial work is planned,provide the information below:
Total floor area(sq. R) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open -
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Depai,twent oflndustrialAccidents
1 . Office oflravestigati.ons
I Congress Street, Suite 100
J Boston, ATA 02II4-20I7
www.niass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Pludnbers
Applicant Information Please Print Legibly
Name (Business/Organizatiott/Individual): PETERSON PARTY CENTER
Address: 36 CABOT RD
City/State/Zip: WOBURN, MA 01801 Phone '�z: 781-729-4000
Are you an employer? Check the appropriate box: Type of project(required):
1.H I am a employer with 200 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner_ listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in an capacity. employees and have workers'
Y p Y 9. ❑ Building addition
[No workers' camp. insurance comp. insurance.?
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. No workers' comp. right of exemption per MGL ❑ p
y [ p 12. Roof repairs
insurance required.]. c. 152, §1(4),and we have no
1 _ ..-- .. _ . 13.❑21 OtherTEMP.TENT...
employees. [No workers'
comp. insurance required.]
Any applicant that checks box;;1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who subant this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such.
+Contractors that check this box must attached an additional sheet showing the name of the sib-contractors and state .Aether or not those entities have
employees. if the seb-roatractes i:a c empi rss.fney must prc%ide the •.vori:er'comp.policy number.
I ran an employer that isproviding workers' compensation insurance far nay employees. .Below is thepo/icy and job site
information.
Insurance Company Name:A I M MUTUAL INS CO
Policy#or Self-ins. Lic.�#::WMZ8006586 f Expiration Date:1019/15
Job Site Address: �/ /� J r City/State/Zip: sG/pm
Attach a copy of the workers' compen ation policy declaration page(showing,the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify
d�
ti/fy under thepaiinss anndpenalties ofperjury that the informationprovided above is true and correct.
Siorrature %/" Z _1 Date
Phone#: 781-729-4000
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1.Board of Health '2. Building Department 3. City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector
6. Other
Contact Person: Phone#:
Commonwealth of Massachusetts , �-
f City of Salem
a i
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120 W ashin ton St,3rd Floor Salem,MA 01970 978 745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Permit No. B-15-703
FEE PAID: $25.00 PERMUT TO BUILDO*
DATE ISSUED: 7/20/2015
This certifies that CINDY DIAZ
has permission to erect, alter, or demolish a building 44 VALLEY STREET Map/Lot: 140082-0
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a5 fOlIOWS: ,.,: PlI�Iilitl f 5 nke ,f s �P"rv.
Other Building Permit TENT PERMIT: r.
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ERECT A 30' X 4T TEMPORARY TENT ON 07/24/2015 AND REMOVE ON 07/26/2015)
FI ni �fr4�lelfdfvFp fief �q s f'' ry,ef, I° tP a�
Contractor Name: pETERSON PARTY CENTER f r •-" •� °' I"�hhf ri �q
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DBA: �I#i
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Contractor License No: CS 060219 �?
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:. "61, I1 rt 7/20/2015
f�� f' Building Official ,yf f E'�4Eel Date
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This permit shall be deemed abandoned and invalid unless thework authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each-upon written i request
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
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All construction,alterations and changes of use of any buildmg,and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. furMR! "� Y
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The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
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HIC#: 'Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL C.142A).
Restrictions: 9 �tt
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Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
I
30x45
FT
12`x1 Dance Floor
OF-I
OMlcP[EMEERMNr_frMI M P®R TA N T DOCUMENT o ,
5 Certif ica�e of 'Flame Resis"ce 5
5 REGISTRATION ISSUED BY 5
Date of Shipment 5
5
v
APPLICATION i aizaizaos 5 NUMBER 4 t INDUSTRIE INC.®
NSVILLE, INDIANA 47725 Tent Identification 5
5 EVA 5
MANUFACTURERS OF THE FINISHED 04337696 5
5 P140.1 TENT PRODUCTS DESCRIBED HEREIN
5 This sis to certify that the materials described have been flame-retardant treated 5
r (or are inherently noninflammable) and were supplied to:657150 5
5 PETERSON PARTY CENTER INC 5
5 139 SWANTON ST 5
5
5 WINCHESTER MA1890
5 - 5
5 5
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the application of said chemical was done in conformance with California 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
r5
5 Serial Jf 5
slo�aol tz� 5
5 - 5 Description of item certified:
5 CENTURY MATE 30WX45 SNYDER
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The 5 Fabric/,J 5 Signed: :4— 4l IL S
5 Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5
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Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
^.rinJtrulllrin SupervVioir
License: C J, 19 N"�: I a
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Mark Traina c,,
33 Hanford Road.
Stoneham MA 02180 p
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Expiration
Commissioner 04/27/2017
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